Gregory Roth, MD, MPH, FACC, et al., looked at the global burden of disease and cardiovascular mortality over the course of 25 years – from 1990 to 2015 – based on the most recent Global Burden of Disease (GBD) study – an international consortium of more than 2,300 researchers in 133 nations.

Results showed that there were nearly 13 million deaths due to cardiovascular disease in 1990, increasing to 17.92 million in 2015; however, significant declines in cardiovascular disease death rates were observed in all high-income and some middle-income countries over the 25-year period. The highest cardiovascular disease death rates occurred throughout Central Asia and Eastern Europe, but also in countries such as Iraq, Afghanistan, and many South Pacific island nations. The lowest rates were in Japan, Andorra, Peru, France, Israel and Spain.

Globally, there were an estimated 422.7 million prevalent cases of cardiovascular disease in 2015, but prevalence varied significantly by country. Countries with the lowest prevalence in 2015, after accounting for population size, included Singapore, Japan, South Korea, Chile, Argentina, Uruguay, Canada, Australia, New Zealand, Ireland, Cyprus, Malta, Italy, Greece and Israel. Western European countries, as well as the U.S., the United Arab Emirates and Nepal, all had only slightly higher prevalence. The countries with the highest prevalence included most countries in West Africa, Morocco, Iran, Oman, Zambia, Mozambique and Madagascar. The authors observed that the steep declines in cardiovascular disease prevalence experienced by the U.S., Canada, Australia, New Zealand, Japan, South Korea and countries in Western Europe over the past two decades have begun to plateau.

There were an estimated 8.92 million deaths due to ischemic heart disease (IHD) in 2015, making IHD the leading cause of death in the world. The highest IHD death rates were observed in Central Asia and Eastern Europe. Globally, stroke and ischemic stroke were the second and third largest cardiovascular disease causes of disability-adjusted life years (DALYs), a combination of information regarding premature death and disability caused by the condition to provide a summary measure of health lost due to that condition, in 2015. DALYs for ischemic stroke outranked other types of stroke only in Central and Eastern Europe and high-income North America. There were an estimated 5.39 million acute first-ever ischemic strokes, 3.58 million acute first-ever hemorrhagic and other strokes, and nearly 43 million prevalent cases of cerebrovascular disease overall in 2015. Other cardiovascular conditions examined include hypertensive heart disease, cardiomyopathy, aortic aneurysm, atrial fibrillation and rheumatic heart disease.

"The prevalence of cardiovascular disease varied widely among countries, and when age-standardized, was declining in many high-income countries," said Roth, et al. "Our analysis of mortality and sociodemographic change demonstrates a global disease gradient, dominated by atherosclerotic vascular diseases such as IHD and stroke and with the most rapid decline occurring only at the highest levels of development. An alarming finding is that trends in cardiovascular disease mortality have plateaued and are no longer declining for high-income regions. Overall, these results demonstrate the importance of increased investment in prevention and treatment of cardiovascular disease for all regions of the world."

Socio-demographic change over the past 25 years has been associated with dramatic declines in rates of cardiovascular disease mortality in regions with a very high sociodemographic index, a measure of development status that combines levels of education, fertility and income, while most regions have experienced a gradual decrease, if any at all. The authors note that it is concerning that large reductions in atherosclerotic vascular disease mortality are no longer apparent in many world regions despite impressive advances in technical capacity for preventing and treating cardiovascular disease.

"The GBD study offers a unique platform for tracking rapidly evolving patterns in cardiovascular disease epidemiology and their relationship to demographic and socioeconomic change," conclude Roth, et al. Moving forward, they explain that "Countries should consider further investment in cardiovascular disease surveillance and population-based registries in order to benchmark their efforts towards reducing the burden of cardiovascular disease. Future updates of the GBD study can be used to guide policymakers who are focused on reducing the overall burden of noncommunicable disease and achieving specific global health targets."

Valentin Fuster, MD, PhD, MACC, editor-in-chief of JACC, echoes Roth's call for the setting of achievable global targets for the treatment and prevention of cardiovascular disease, pointing out what he calls, "the manifestation of two paradoxes" in the paper. "First, we keep discussing how much we have progressed among our subspecialty, yet the paradox is that the disease state remains the number one killer in the world," says Fuster. "The second paradox is that medicine remains very expensive, yet we don't put efforts into promoting health at younger ages, which could be a cost-effective method to preventing the onset of the disease. Instead, we continue to only invest in treating advanced manifestations of cardiovascular disease."

In a related editorial comment, Dariush Mozaffarian, MD, FACC, describes a shift in the noncommunicable diseases plaguing the global population and provides next steps for addressing present obstacles. "These findings confirm that the epidemiologic 'transition' away from infectious and maternal-child diseases and toward noncommunicable chronic diseases has already occurred globally – a sobering reality as countries around the world consider their priorities for health care, public health prevention, and economic growth." Moving forward, Mozaffarian suggests the implementation of policies targeting lifestyle behaviors, particularly smoking, suboptimal diet and physical inactivity.